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' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)4683420 <br /> P 0 BOX 2009, STOCgTON, CA 95201 <br /> �d <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS <br /> (Complete in Triplicate) <br /> p�}�g�+�k�teff' described. This <br /> ti`l ' ttil,rs and Regulations of San <br /> Application is hereby made.Lo San Joaquin County for a permit to construct and/or install <br /> application is made in compliance vith San Joaquin County Ordinance No. 544 and 1862 and I <br /> Joaquin County Public Health Services. fi� ) ' <br /> Job Address <br /> S City tom`PERMIT <br /> p <br /> CA � Phone <br /> Qr�lyAddress r Q (A <br /> Owner's Name 1 )3 <br /> Contractor ddress <br /> �e �Tl License No, Phone <br /> z <br /> LL REPLACEMENT 1 1 DESTRUCTION LJ Out of Service Well <br /> WE <br /> TYPE DF WELL/PUMP'. NEW WELL OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES__�---- DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � OTHER WELL PITSISUMPS <br /> FOUNDATION — AGRICULTURE WELL �tC�iF <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICASkOt�S Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Industrial e.1_ eQ, Q1/� Specifications <br /> �I Gravel Pack ❑ Tracy Type of Casing —r.— A <br /> [-1 Domestic/Private ( � Type of Grout <br /> 1-1 Other 11 Delta Depth of Grout Seaf <br /> i'1 Public Surface Seal Installed by <br /> I I Irrigation a_SD Approx. Depth I I Eastern H.P. State Work Done — <br />' Repair Work (Sone U Type of Pump Sealing Material Depth <br /> Well Destruction ❑ Well Diameter Filler Material f: Depth <br /> Depthic <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l I DESTRUCTION I I (Nose <br /> lvailabi within 200 stem feet.) if public sewer is <br /> + Installation will serve: Residence— Commercial — Other �-- <br /> k Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity❑ Type/Mfg No. Compartments <br /> SEPTIC TANK- Method of Disposal <br /> PIkG, TREATMENT PLT. ❑ property Line <br /> Distance to nearest: Well Foundation �- <br /> PAYMENIr <br /> Total length/size <br /> LEACHING LINE DNa. & Length of lines Property Line <br /> FILTER BED 0 Distance to nearest: Well Foundation ^� <br /> 1 12 <br /> N <br /> SEEPAGE PITS 11 Depth Sire Number COUNTY <br /> property Line_EL1B.LCC-UEALTH SERVICES <br /> SUMPS L1 Distance to nearest: Well Foundation ENVIRONMENTAL HEA <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws. and <br /> ! hereby certify that I have prepared this application and <br /> rules and regulations of the San Joaquin County <br /> agent's ing: "I certify that in the performance of the work for which this permit is issued, i shall not <br /> Home owner or licensedsignature certifies the follow <br /> employ any person in d a manner to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa <br /> tion laws of Californla." <br /> The applicant must call far Il re uired i tions. Complete drawing on reverse side. <br /> Date: <br /> Title: <br /> Signed X <br /> FONT USE ONLY �- <br /> Date.�3'�y A2" Area <br /> Application Accepted by <br /> Pit or au inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> r Environmental Health Permit/Services <br /> 445 N San Joaquin, P 4 Box 2009, Stkn, CA 95201 <br /> GK RECEIVED BY DATE PERMIT NO, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO A <br /> . EH 13-24 IfIEV.I/w 51 W tIo � <br /> EH 14.2E l <br /> E <br />